Charlottesville Gynecology
Gwendolyn V. Kelly, MD
Practice Information and Financial Policies Agreement
Welcome to the gynecologic practice of Dr. Gwendolyn Kelly.
I specialize in office-based gynecologic care and women’s preventive health.
In addition to caring for you at your annual “check-up”, I can offer expert advice on abnormal bleeding,
abnormal paps, pelvic pain, infections, contraceptive options, vaccinations, and other gynecologic concerns.
I will personally communicate with you regarding your test results (paps, ultrasounds, blood work, etc.). I
always send out letters if the results are normal/benign, and I always make personal phone calls if there is an
abnormality. If you do not hear about the results of your test within a month, PLEASE call our office. This way
nothing can “slip through the cracks”. The exception to this is with mammography: all normal mammograms
are communicated to you directly from the radiology department. However, for abnormal mammograms, this
office will call you to arrange the appropriate next steps. Again, if you do not hear about your mammogram
within a month, PLEASE call our office.
I do not perform surgeries and I do not deliver babies.
If you need an operation, or if you become pregnant, I will refer you to one of my gynecologic surgical or
obstetrical colleagues, who I am confident will provide you with excellent care (and, who will communicate
regularly with me).
I do not have partners, but I always carry a pager for urgent medical problems that cannot wait until regular
office hours. On the rare occasion when I am out of town, I will call in to check for messages regularly. If you
have a medical emergency that requires immediate attention, you must dial 9-1-1. If you need urgent attention
and I am unable to meet you in my office, I suggest you go to the Emergency Department with which your
primary care physician (PCP) is affiliated. I have chosen to become a “Courtesy Staff” of Martha Jefferson
Hospital. While I will not be able to be your direct care provider in the event that you are hospitalized, I will be
able to communicate directly and frequently with those who are caring for you during your hospital stay.
Consent to Medical Care:
• I voluntarily consent to medical care at Charlottesville Gynecology Specialists, which may include examinations, tests, and
treatments by doctors and the staff. No promises have been made as to the results of the examinations or the treatments.
• I hereby authorize the release of any pertinent medical information to other doctors involved with my case.
• I hereby authorize the release of any medical information required to process my insurance claim. I also authorize my
insurance benefits to be paid directly to the physician and understand that I am financially responsible for all services
provided.
Deemed Consent for Blood Borne Pathogens:
• Virginia law requires health care providers to notify you that Hepatitis B and C and HIV testing on a sample of your blood
may be done if a health care worker is exposed to your blood or body fluids. This notice is to advise you that this is in effect
at this facility. As a health care provider under the Virginia Acts of Assembly Section 32.1-45.1, whenever any health care
worker associated with or working for Charlottesville Gynecology Specialists is directly exposed to body fluids of a patient
in a manner which, according to the guidelines of the CDC, may transmit HIV or Hepatitis B and C, Charlottesville
Gynecology Specialists will proceed to test the patient and the health care workers who were exposed for HIV, Hepatitis B
and Hepatitis C.
600 Peter Jefferson Pkwy, Suite 200. Charlottesville, VA 22911 Phone: 434-296-6461- Fax: 434-296-7529 www.charlottesvillegynecology.com
Charlottesville Gynecology
Gwendolyn V. Kelly, MD
Financial Policy Agreement


Private Insurance - As a courtesy to our patients, we file most insurances. Your insurance must be current and verifiable at
the time of your visit. Payment assignation must be made to this office. Please be aware that some or perhaps all of the
services rendered may or may not be covered, including vaccines. If your insurance company denies payment, you will be
billed for any balance due. We cannot file your insurance unless you have your card with you. If you do not have your
insurance card with you, you can either reschedule your visit or you can be seen as a “self-pay” for that particular visit. If you
do not submit the correct insurance card at the time of your visit, you will be considered self-pay and any services rendered
on the day of your visit will be your responsibility. If your insurance company fails to pay their portion of outstanding
charges after 90 days, the account will be automatically turned over to you and the balance due will become your
responsibility.
Secondary Insurances – Due to the small size of our practice, we unfortunately cannot file any secondary insurances.

Private Payments -Co-pays, deductibles, past due balances, and payments for non-covered items are due at the time of
treatment. We accept cash, checks, and credit cards. A $30 fee will be assessed for all returned checks. A $25 late fee will be
charged if payment is not made in full by the payment due date. Each time an unpaid statement needs to be reprocessed;
subsequent $25 late fees will be assessed to the overdue account.

Collections - Should it become necessary to utilize outside collection means for a past-due account, you are responsible for
all associated collection costs, including attorney, court, and collection fees. You will also be assessed a $50 penalty fee to
cover the costs of warrants and other associated costs. If we are forced to turn your account over to a collection agency, you
will be automatically terminated from our practice.

Co-payments and Balances - In an effort to decrease the cost of medical care, it is mandatory for you to provide your
insurance card and a credit card or at the time you check in.
o This information will be held securely in your medical chart until your insurances have paid their portion. Once
insurance payment is received, any remaining balance will be billed to your credit card and you will be mailed a
receipt.
o We appreciate the confidence you have placed in us by trusting us with your health care. By managing costs in this
manner, we can continue to offer the highest quality care at a reasonable price.
o Your insurance and credit card information will be stored solely in your medical record (NOT in a computer).
Medical records are protected by strict federal laws and are secured according to these regulations. Providing this
information in no way poses a risk of identity theft or credit card fraud. In fact, your credit card information is safer
here in your medical chart than it is when you purchase gasoline, rent a car, stay at a hotel, or buy groceries.
o This will not compromise your ability to question your insurance company’s determination of payment.
Appointment Notification Policy:
We usually call patients the day before appointments as a courtesy reminder. If you are not available at the time, we will
leave a message saying “Hello, this is Charlottesville Gynecology calling to remind you of your appointment on this date /
time”. Unless you tell us in writing that this is not your preference, you are granting permission for us to call & leave a
reminder message for your appointment.

Appointment Cancellation Policy:
As a courtesy, we request that you give us 24 hours notice if you are unable to make an appointment. When someone does
not show up for a scheduled appointment, a time slot is missed by someone else who needs prompt medical care. Because
some individuals are repeated “no-shows”, we are regretfully implementing a $50 charge for missed appointments.

Referrals:
I understand that my medical insurance company may require a referral. I understand that I am responsible for ensuring that
the referral has taken place prior to my office visit here. If I have not obtained the referral at the time of my appointment, I
understand that I am financially responsible for any charges incurred during the office visit, if these are not covered by my
insurance company.
600 Peter Jefferson Pkwy, Suite 200. Charlottesville, VA 22911 Phone: 434-296-6461- Fax: 434-296-7529 www.charlottesvillegynecology.com
Charlottesville Gynecology
Gwendolyn V. Kelly, MD
Laboratory/ Radiology/Pathology Policy:
This practice uses the Martha Jefferson’s Lab, CRL Radiology, and Charlottesville Pathology for all pap smears, blood
draws, cultures, mammograms, ultrasounds, MRIs, and other testing deemed necessary during your visit. If your insurance
policy states that an alternate lab must be used, it is your responsibility to notify all members of our staff (front desk, nurse,
and health care provider) so that the appropriate arrangements can be made. This practice is not responsible for fees
incurred by your visit with us from Martha Jefferson’s Laboratory, Charlottesville Pathology or any of Martha
Jefferson’s imaging centers. Most of the time, you will receive a separate bill for the tests you have had done. If you have
a question about that bill, please call the phone number on that bill directly.

Prescription Refills – Dr. Kelly always gives enough medication refills to last until you are due for your next scheduled
appointment. Please be sure to ask Dr. Kelly for any additional prescription needs that you have while you are here in the
office. There is a $25 fee to call in all prescription refills to the pharmacist once you have left the office. Please be sure to get
all of your written prescriptions before your leave this office to eliminate the need for any refill requests.

Record Requests –There is a $40 charge to have the medical record copied and sent to a separate facility.

Protected Health Information (HIPPA): I acknowledge that I have received or been offered a
copy of Charlottesville Gynecology Specialists Notice of Privacy Practices.
 I consent to the use and disclosure of my protected health information by Charlottesville Gynecology Specialists and its
medical staff for the purposes of treatment, payment, and heath care operations.
 I give consent to Charlottesville Gynecology Specialists PC, its Medical Staff, and other providers involved in my care
to use and/or disclose my protected health information for the purposes of treatment, payment, and health care
operations.
 I understand health care operations may include among other things uses or disclosures relative to quality review,
utilization review, medical necessity, or legal review.
 Protected health information may include medical records, insurance and payment information, and other information
used, in whole or in part, to make decisions about me. Charlottesville Gynecology Specialists Notice of Privacy Practices
provides more information about how Charlottesville Gynecology Specialists, its Medical Staff, and other providers may
use and disclose my protected health information for these purposes.
My signature confirms that I have read and that I understand all of the information provided to me in
this entire document, and that I agree to the terms of the doctor-patient relationship as described above
for the practice of Gwendolyn Kelly, MD
Signature:
_______________________________________
Printed Name:
_______________________________________ Date: ___________________
How did you hear about us?
 Charlottesville Family Go-To Guide
 Internet
 Friend
 Physician’s Office
 Other:_______________________
600 Peter Jefferson Pkwy, Suite 200. Charlottesville, VA 22911 Phone: 434-296-6461- Fax: 434-296-7529 www.charlottesvillegynecology.com
Charlottesville Gynecology
Gwendolyn V. Kelly, MD
Please list all prescription medications.
Medication Name:
Purpose/Diagnosis:
Please list vitamins or supplements that are taken DAILY.
Name:
Purpose/Diagnosis:
Which pharmacy do you use?________________________________
Location:________________________
Thank you!
600 Peter Jefferson Pkwy, Suite 200. Charlottesville, VA 22911 Phone: 434-296-6461- Fax: 434-296-7529 www.charlottesvillegynecology.com